Video-Assisted Thoracoscopic Surgery versus Robotic-Assisted Thoracoscopic Surgery Thymectomy

Minimally invasive subxiphoid-right, videothoracoscopic technique of thymectomy for thymoma and rethymectomy

Minimally invasive subxiphoid-right, videothoracoscopic (VATS) technique of thymectomy for thymoma is presented. This approach enables complete removal of the whole thymus, with visualization of the lower poles of the thyroid. The whole dissection is performed through the 4-7 cm subxiphoid approach with single 5-mm port insertion into the right chest cavity for the thoracoscope and, subsequently for the chest tube. The sternum is elevated with two hooks connected to the sternal frame. The lower hook is inserted through the subxiphoid incision and the superior hook is inserted percutaneously after the mediastinal tissue including the major mediastinal vessels that are dissected from the inner surface of the sternum. Generally, the left mediastinal pleura is not opened. The fatty tissue of the perithymic, right pericardiophrenic and aorta-pulmonary window can be completely removed. The dissection of the lower neck, aorta-caval groove and the left pericardiophrenic areas are not as complete as in the previously reported transcervical-subxiphoid, -bilateral VATS maximal thymectomy, however, therefore, the subxiphoid-right VATS technique of thymectomy have been used for early stage thymomas, not for non-thymomatous Myasthenia gravis. In this article, some important steps facilitating safe and straightforward performance of the procedure are presented and the methods of management of intraoperative complications are discussed.

Hybrid combination of small subxiphoid incision and thoracoscopic thymectomy for juvenile myasthenia gravis

BACKGROUND/PURPOSE

Myasthenia gravis is an autoimmune disease that usually responds positively to treatment with thymectomy. Various approaches via video-assisted thoracic thymectomy as a substitute for conventional sternotomy have been reported. We reported a less invasive technique for thymectomy in pediatric groups.

METHODS

Four adolescents with juvenile myasthenia gravis all underwent hybrid combination of small subxiphoid incision and thoracoscopic thymectomy at our institute. Clinical characteristics and surgical outcome were consecutively collected.

RESULTS

In these 4 patients, 2 presented with Osserman class III and 2 with class IIb. The mean operative time was 180 minutes. There was no conversion to sternotomy, and there was only minimal blood loss. Follow-up duration was 3 to 64 months. Postoperatively, 1 patient had complete remission and 3 patients had improvement in clinical symptoms.

CONCLUSION

Hybrid combination of small subxiphoid incision and thoracoscopic thymectomy may be an effective alternative with low surgical invasiveness for treating juvenile myasthenia gravis.

Management of myasthenic patients with thymoma

Myasthenia gravis (MG) associated with thymomas differs from nonthymomatous MG, and thymomas associated with MG are also different from non-MG thymomas. According to the World Health Organization classification, the incidence of MG in thymomas was the highest in the subtypes B2, B1, and AB. Transsternal approach is still regarded as the gold standard for surgical treatment of thymomas. Less-invasive techniques of thymectomy are promising, but it is too early to estimate their real oncological value. In the series including more than 100 patients, the prognosis for survival is better in patients with thymomas associated with MG than in those with non-MG thymomas, and the prognosis for patients with MG associated with thymoma is worse than that for patients with nonthymomatous MG.

Video-assisted thoracic surgery thymectomy: the better approach

Minimally invasive video-assisted thoracic surgery (VATS) thymectomy has evolved significantly over the last decade. The most common indication for VATS thymectomy is the treatment of myasthenia gravis (MG). Video-assisted thoracic surgery thymectomy results in less postoperative pain, better preserved pulmonary function, and improved cosmesis, which can be particularly important to many young female MG patients. Results of VATS thymectomy, in terms of complete stable remission from MG and symptomatic improvement, as well as safety, are comparable with conventional surgical techniques. This more patient-friendly approach would lead to wider acceptance by MG patients and their neurologists for earlier thymectomies and improved outcomes.

(18)F-FDG PET/CT is Useful for Pretreatment Assessment of the Histopathologic Type of Thymic Epithelial Tumors

PURPOSE

This study was performed to assess the usefulness of (18)F-fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET) or PET/computed tomography (CT) for distinguishing thymic epithelial tumors according to World Health Organization (WHO) classifications.

METHODS

We analyzed a total of 45 patients (range, 29-75 years of age; mean, 55 years) with pathologically confirmed thymic epithelial tumors who underwent pretreatment (18)F-FDG PET or PET/CT between November 2003 and October 2009. The size, visual grading of uptake value, peak standardized uptake value (SUVpeak), uptake pattern, and contour of each tumor, and associated findings on PET or PET/CT, were analyzed relative to the three simplified WHO subgroups: less-invasive thymomas (types A and AB), more-invasive thymomas (types B1, B2, and B3) and thymic carcinomas. We statistically assessed the relationship of (18)F-FDG PET or PET/CT findings with these simplified subgroups.

RESULTS

Of the 45 patients, ten had less-invasive thymomas, 23 had more-invasive thymomas, and 12 had thymic carcinomas. The SUVpeak of the less- and more-invasive thymomas were significantly lower than those of thymic carcinomas (p < 0.000), but there was no difference in SUVpeak between less- and more-invasive thymomas. The visual grading scale (p < 0.000), uptake pattern (p = 0.001), and contour (p < 0.000) of the tumors differed significantly among the three simplified subgroups.

CONCLUSION

The image findings of (18)F-FDG PET or PET/CT differed significantly by histologic subgroups. Pre-treatment evaluation with (18)F-FDG PET or PET/CT might be helpful in differentiating subgroups of thymic epithelial tumors.

Surgical treatment of thymic epithelial neoplasms

Resection continues to be the mainstay of treatment for epithelial lesions of the thymus. This has never been in doubt for encapsulated stage I and II lesions, but we recently have come to a greater appreciation of the role of preoperative therapy for locally advanced lesions, particularly stage III disease. For any lesion that presents in the anterior mediastinum and on CT scan does not appear to be eminently resectable, a biopsy should be performed to rule out lymphoma after serum germ cell markers have been obtained to rule out the rare primary mediastinal or metastatic germ cell tumor.